Case
Focused Exam Pain Management Completed Shadow Health- Subjective Data Collection
- Institution
- Chamberlain College Of Nursing
Focused Exam Pain Management Completed Shadow Health- Subjective Data Collection
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Focused Exam: Pain Results | Turned In
Medical Surgical Nursing: Promoting Wellness in the Older Adult - January 2020, nurs201-da_nurs201_202001spi_befghjk
Return to Assignment (/assignments/304559/)
Your Results Lab Pass (/assignment_attempts/6203901/lab_pass.pdf)
Overview
Subjective Data Collection: 58 of 58 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
QSEN Competencies
Example Questions.
Documentation
SBAR
Category Scored Items Patient Data
Reflections
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of the
patient's case.
Page 1 of 8
Chief Complaint
Established chief complaint Reports pain Reports recent fall
Reports
worry
about
worsening
symptoms
Orientation
Established orientation Oriented to person Oriented to place Oriented to time O
Patient Status
, Focused Exam: Pain | Completed | Shadow Health
Asked about medication administered in ER Reports receiving oxycontin
Reports oxycontin has been effective
Asked about patient comfort and needs Denies needing to use the bathroom
History of Present Illness
Asked about onset and duration of symptoms Reports recent episode of severe pain started this
morning
Reports pain has been getting progressively
worse in the last few weeks
Asked about location of pain Reports hip pain
Reports knee pain
Asked about characteristics of pain Describes pain as aching
Describes pain as "deep"
Denies shooting or sharp pain
Reports occasional "grating" sensation in joints
Denies burning pain
Denies stinging pain
Asked about severity of pain Reports current pain is a 1
Reports pain before medication was a 9
Asked about non-medication relieving factors of Reports that rest typically relieves the pain
pain Reports not using any non-medication treatments
to treat this morning's pain
Reports occasional use of moist heat as treatment
on hips
Reports using range of motion exercises for knees
Reports wearing elastic supports on knees
bilaterally
Denies use of ice as treatment
Asked about aggravating factors of pain Reports that exercise exacerbates pain and
stiffness
Reports that weight bearing exacerbates pain and
stiffness
Reports that pain and stiffness are worse in the
morning
Reports that changes in weather exacerbate pain
and stiffness
Followed up on details of the fall Reports falling getting out of bed
Reports hitting his back on bed frame
Denies dizziness, syncope, or vertigo at time of
fall
Denies substance use that could have related to
the fall
Page 2 of 8
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